WOUND HEALING

Contents :
Wound healing Regeneration & repair Healing by primary intention & secondary intention Healing in fractures Healing of extraction socket & its complications Factors influencing wound healing Methods of control of hemorrhage

Causes
Prevention Management Prosthetic considerations

INTRODUCTION
What is a "WOUND"..?? -- its any injury to the tissues or the organs caused by a cut, stab or tear, usually going deeper than the outer skin. what is "HEALING"...??

--Is the body's response, to injury, to restore normal structure and function.

Therefore, WOUND HEALING, is the body's ability to repair the injured tissues, by:

1) replacement of the injured or dead cells by the new cells of the same kind, i.e. Regeneration.

2) replacement by the connective tissue, i.e. Fibrosis.

REGENERATION: --Healing takes place by proliferation of the parenchymal cells and usually results in complete restoration of the original tissues, leaving no residual trace of the previous injury. --cell proliferation can be stimulated by cell injury, cell death and mechanical deformation of the tissues

depending upon their capacity to divide cells of the body are divided into 3 main groups: 1) LABILE CELLS (continuously dividing cells) 2) STABLE CELLS (quiescent cells) 3) PERMANENT CELLS (non-dividing cells)

REGENERATION: G0, G1, S, G2 PHASE

REPAIR: -- its the replacement of the injured tissues by the fibrous tissue formation i.e. Fibrosis. -- repair begins early in inflammation, fibroblasts and vascular endothelial cells begin proliferating by 3-5 days to form a very specialized tissue that is the hallmark of the healing process, called the, Granulation tissue.

it occurs in two main steps as follows: 1. granulation tissue formation: 2. contraction of wounds:

Granulation tissue formation 1. phase of inflammation 2. phase of clearance 3. phase of ingrowth of granulation tissue -- angiogenesis -- fibrosis

Contraction of wounds:
(a) dehydration (b) contraction of the collagen (c) discovery of the myofibroblasts

Scar formation
Fibroblast migration & proliferation

ECM deposition & Scar formation

Tissue remodeling (metalloprotenases)

** WHY NO SCAR FORMATION IN THE ORAL CAVITY? -- The oral cavity has many structurally different tissues that likely heal in different ways. Periodontists and oral surgeons are well aware that incisions in the buccal mucosa result in scars, whereas harvesting gingival grafts from the palate produces no visible sign of scarring. In addition, incisions in the gingiva itself heal without scars.

-- Various reasons have been suggested for minimal scarring in the oral cavity, including distinct fibroblast phenotype, the presence of bacteria that stimulate wound healing and the moist environment and growth factors present in saliva.This effect of saliva is attributed mainly to its relatively high concentration of epidermal growth factor (EGF), and topical use of artificial saliva has been suggested as a treatment for skin burn wounds.

Wound Healing:
Inflammation Epithelialization Granulation Contraction Remodeling

Healing by Primary Intention:

Healing of clean, uninfected, surgical incisions Focal disruptions of basement memb. Continuity Within 24 hrs. Netrophils Inc. mitotic activity of basal cells Cells meet in midline below scab

Day 3 : Neutrophils replaced by macrophages Invasion of granulation tissue Vertically oriented collagen fibers Thick epithelial covering

Day 5 :
Neovascularisation peak Abundant collagen fibers Differentiation - keratinisation

During 2nd week:

Continued collagen accumulation & fibroblast proliferation Vascularity, edema, leukocyte infiltration decrease Collagen inc.

By end of 1st month:

Scar devoid of inflammatory cells Dermal appendages lost permanently Tensile strength inc.

Healing by Secondary Intention:

More extensive wounds infarcts, inflamm. Ulcers, abcess or large wounds Healing from below upwards & margins inwards

Slow & leads to scar formation

Initial hemorrhage:
Wound filled with blood & fibrin clot

Inflammatory phase:
Acute inflamm cells, then macrophages

Epithelial changes:
Proliferation from both margins Surface not covered till granulation tissue starts filling wound space Scab cast off

Granulation tissue:
Main bulk Fibroblasts & neovascularisation Deep red, granular & fragile but pale

Wound contraction:
Not seen in primary healing Due to myofibroblasts 1/3 the original size

Healing by secondary intention

Wound Strength
Sutured wounds 70% of unwounded skin 1 week- 10% 4 week- inc 3 month- 70-80% No further increase

Complications
Infection Pigmentation Implantation Deficient scar Hypertropied scar & Keloid Excessive contraction Neoplasia Incisional hernia

Factors influencing healing

A) LOCAL FACTORS
1) infections 2) poor blood supply 3) foreign bodies 4) movement 5) exposure to the ionising radiations 6) UV-Light

B) SYSTEMIC FACTORS 1) Age 2) Nutrition 3) systemic infection

4) administration of the glucocorticoids

5) uncontrolled diabetics 6) haematological disorders

HEALING IN THE SPECIALISED TISSUES: FRACTURE HEALING

Healing of the fracture by callus formation

However the basic events in the healing of any type of fractures is similar and resemble healing of the skin wound to some extent.

*** PRIMARY UNION OF FRACTURES:

-- it occurs in few special conditions when the ends of the fracture are approximated and is done by the application of the compression clamps.

-- in these cases the bony union takes place with formation of the medullary callus without the periosteal callus formation.

*** SECONDARY UNION OF THE FRACTURES:

-- its a more common process of fracture healing. -- though its a continuous process its described under following headings: 1) PROCALLUS FORMATION: -- Haematoma -- Local inflammatory response -- ingrowth of the granulation tissue -- Callus composed of the woven bone and the cartilage

2) OSSEOUS CALLUS FORMATION: -- the procallus acts as a scafolding over which osseous callus composed of lamellar bone is formed. -- The woven bone is cleared away by the incoming osteoclasts and the calcified cartilage disintegrates. -- in their place newly formed blood vessels and the osteoblasts invade, laying down the osteoid which is calcified and the lamellar bone is formed by developing the Haversian system around the blood vessels.

3) REMODELLING: -- during the formation of the lamellar bone, both the osteoblastic and the osteoclastic activity takes place, thus remodelling the united bone ends, which are sometimes indistinguishable from the normal bone.

-- External callus is cleared away.

-- Intermediate callus gives place to the compact bone. -- Internal callus develops the bone marrow cavity in it.

Healing of extraction socket

Healing Of Extraction Socket

Immediate Reaction : Blood fills the socket & coagulates Torn blood vessels sealed off Vasodilation & engorgement Leukocytes around the clot

First Week Wound : Fibroblast proliferation Clot acts as scaffold Mild mitotic activity Clot organization, no osteoid formation

Second Week Wound :

Clot organization progresses Remnants of PDL degeneration Epithelial Proliferation Socket margins osteoclastic activity

Third Week Wound :

Clot totally organized Osteoid bone formation Rounded crest Complete epithelisation of surface

Fourth Week Wound :

Continuous remodeling & deposition Crest below adjacent tooth Radiographic evidence 6-8 weeks

Complication of socket healing

Dry Socket/Alveolitis Sicca Dolorosa/Alveolitis Osteitis/Acute Alveolar Osteomyelitis/Alveolagia
Most common disintegration of clot 95% in lower premolars & molars Within 2nd or the 3rd day Extremely painful Palliative medicine & dressings Reviewing the patient Pack socket with obtundant

-- First time the term "DRY SOCKET" was used by Crawford in 1896.
-- its a post-operative complication that occurs after a dental extraction.

-- its defined as "postoperative pain in and around the dental alveolus, which increases in severity during the 1st and the 3rd day, after a dental extraction, accompanied by a partial or total disintegration of the intra-alveolar clot, accompanied invariably with a foul smell.

The condition derives its name from the fact that after the clot is lost the socket has dry appearance because of exposed bone.

** It may occur due to frequent and forceful spitting after extraction, smoking or excessive traumatic extraction. Disintegration of clot may be due to infection of the wound. Bacterial enzymes hyaluronidase and fibrinolysin causes lysis of clot. **The bone of the socket becomes necrosed, grayish bone is seen from the socket and bad odor is present at the socket and pus is minimal or not at all.

** For the treatment of dry socket, intra-alveolar pastes consisting of the zinc oxide eugenol paste, anaesthetic and an antibiotic (metronidazole) can be placed. A strip of paste soaked surgical gauze should be placed gently into the socket.

** Antibiotics and analgesics are not effective if used alone because of poor vascularity of the necrosed bone.

Fibrous healing
+Rare Loss of labial & lingual plates Dense fibrous mass on exploration This loss of cortical periosteum causes improper healing and scar tissues are found at the site. These fibrous connective tissue may ossify a little or not at all. For the Treatment, excision of the lesion for the purpose of establishing a diagnosis will sometimes result in normal healing and subsequent bony repair of the fibrous defect.

Methods to control Hemorrhage:

Causes: some amount of bleeding is normal after an extraction. This usually stops after the application of the pressure in a couple of minutes. Excessive bleeding will be seen in hypertensives and where a blood vessel has been severed.

Prevention: excessive bleeding can be prevented by the atraumatic extraction. In the hypertensives make sure that the blood pressure is under control before the extraction.

-- patients on the anticoagulants should be investigated properly and a physician's opinion should be taken.
-- incision should be planned properly to avoid any damage to the major vessels.

Management:
1) Pressure pack: -- the first line of management is to apply the pressure on the bleeding site. A gauze moist with saline may be used to apply the firm finger pressure on the area.

2) Visualise: -- if the bleeding does not stop then a properly cleaning the the area and then examination is done under proper light, to visualise the region and examine.
-- look for the spot of the bleeding, if the bleeding is from the soft tissue area, pressure will stop the bleeding. -- if its from the bone then locate the exact point and then open up a gauze piece to make a thin strip and pack tightly into the socket to prevent the bleeding.

3) Local anaesthetic packs:

-- these are easily available in the clinics and so can be used for temporarily control the bleeding. But these shouldnt be used as a permanent solution as once the effect wears off the bleeding may start again

4) Sutures: -- bleeding from the soft tissues may be controlled by placing the sutures as this helps to compress the mucosa against the bone and reduce the bleeding.

5) Cautery: --bleeding from the bone may be controlled by the cauterisation. The exact bleeding point is first located. -- the area is first dried as much as possible and then a hot ball burnisher may be used to cauterize. -- electrocautery may also be used for the same.

6) Ligation: -- if a major artery is severed, then it may be needed to be ligated.

7) Gel foam: -- this is a gelatin based sponge, which acts by disrupting the platelets and establishing a framework with fibrin strands to create a clot. It gets absorbed within 4-6 weeks.

8) Oxidised Cellulose: -- it releases the cellulosic acid, which has a marked affinity for the hamoglobin, leading to the formation of the artificial clot. -- these substances may be placed in the socket to enhance the clot formation and thus control the bleeding. 9) Fibrin Glue: --this consists of a fibrinogen and thrombin, which thus when applied leads to decrease the bleeding by stabalising the clot formed.

10) Bone Wax: -- this is the mechanical agent to block the bleeding vessel. --bleeding from the bone may be occluded by placing small piece of bone wax firmly on the spot of bleeding.

--The patient should be made to wait for some time after extraction in the clinic to confirm the absence of the bleeding.

** PROSTHETIC CONSIDERATIONS:

** IMPRESSIONS MAKING : -- Any impression making, should be carried out only when the extraction sockets and the oral mucosa are completely healed. -- If any unhealed sockets are present then the patient is asked to wait till the healing is complete.

-- Once the gum tissues and bones of the jaw have completely healed--which may take at least six to eight weeks, according to the American Dental Association--the patient can be fitted for a set of permanent dentures.

-- impressions of the unhealed sockets will lead to the pain and discomfort during the procedure and the dentures prepared will not fit as afterwards the healing would have taken place along with the bone formation in the socket.

** IMMEDIATE DENTURES:
-- its a complete denture or a removable partial denture, fabricated for the placement immediately after the removal of the natural teeth.

-- These immediate dentures, help to protect the gums, as well as numbing the pain. -- Troublesome hemorrhage is rare because the immediate dentures act as a bandage themselves.

-- less post-operative pain is likely to be encountered because the extraction sites are well protected by the immediate dentures.

-- as tissue conditioning materials are used for the correction and the refinement of the dentures fitting surface, so care should be taken so that the material does not get into the extraction socket. And for this the extraction socket is covered by the "BURLEW FOIL".

-- also, any projections of the tissue conditioning material inside the denture should be trimmed because if this is overlooked, normal socket healing will be then compromised and the ridge will heal with small concavities overlying the extraction sockets leading to the formation of the "KNUCKLE SHAPED RIDGES".
-- dentures should not be removed during the first 24 hours as inflammation and swelling can occur and if the dentures are removed then its difficult to reinsert them for 3-4 days, due to swelling.

** IMMEDIATE IMPLANT PLACEMENT: -- Dental implants can be placed in fresh sockets immediately after tooth extraction. These are called "immediate" implants.

-- "Immediate-delayed'" implants are those implants inserted after one or more weeks, up to a month or more, to allow for soft tissue healing.
-- "Delayed" implants are those placed thereafter in partially or completely healed bone.

-- The advantage of immediate placed implants is the shortened treatment time. Bone height will be maintained thus improving implant bone support and aesthetic results.
-- The extraction socket can have an implant placed immediately after a Chronically infected tooth is removed, but needs to have the replacing implant anchored into bone and the site grafted at the same time with a PTFE membrane that excludes soft tissue, allowing the bone grafted socket site to heal normally with the newly placed implant.

** WOUND HEALING IN DIABETICS: -- delayed wound healing occurs in the diabetics due to the decreased polymorphonuclear chemotaxis.
-- they are more prone to the infections as the gingival fluid too contains more of the glucose levels which favors the growth of the microflora. -- Delayed vascularization, reduction in blood flow, decline in innate immunity, decreases in growth factor production, and psychological stresses may be involved in the protracted wound healing of the oral mucosa in diabetics

-- Poor circulation: If you have had diabetes for a long while, you probably have fatty deposits in your arteries that slow down blood flow causing poor circulation. Poor circulation can limit the amount of oxygen and healing nutrients that reach a wound. -- Endothelial progenitor cells (EPCs), which derive from bone marrow, normally travel to sites of injury and are essential for the formation of blood vessels and wound healing.

-- the numbers of these vital EPCs are decreased in the circulation and at wound sites in diabetes.

-- The high oxygen levels increased the activation of the bone marrow enzyme eNOS, which stimulated nitric oxide production, helping to produce greater numbers of EPCs.
-- impaired eNOS activation in diabetes are responsible for the defect in diabetic wound healing.

CONCLUSION: Wound healing is a complex and dynamic process of restoring cellular structures and tissue layers. Its of importance to a prosthodontist in a way as it determines the time during which the prosthesis can be given to the patient. There are various factors which effect the wound healing and we should know all the factors which effect the period of wound healing.

REFERENCES:
*Robbins & Cotron Pathological basis of diseases -7th edn. *Essential pathology for dental students Harsh mohan,3rd edn. *Textbook of oral & maxillofacial surgery Balaji. *Human embryology - Inderbir Singh 4th edn *Prosthodontic Treatment for Edentulous Patients *Bouchers 12th edn *Essentials of complete denture Prosthodontics Winkler, 2nd edn